Using the CDA Consolidation Guide to Make Sense of MeaningfulUse Stage2 Summary Care Records

Here is my next installment in making sense of the Meaningful Use Summary Care Record definitions.  On Tuesday I explained the problem.  Yesterday, I mapped each of the regulations into different data elements.  Today, I show how each of these can be implemented using the required standard:  The CDA Consolidation Guide.

There are two tables below.  The first one maps data elements in the CDA Header.  These are supported in all CDA Documents (not just those in the Consolidated Guide).

Header Data Elements	CDA Location
Name	patient/name
Gender	patient/administrativeGenderCode
Date of Birth	patient/birthTime
Race	patient/raceCode
Ethnicity	patient/ethnicityCode
Preferred Language	patient/languageCommunication
Provider Info	encompassingEncounter/responsibleParty
Visit Date	encompassingEncounter/effectiveTime
Visit Location	encompassingEncounter/location
Care Team Members	documentationOf/serviceEvent[@classCode'PCPR']/performer

The second table maps data elements to CDA Sections, listing the CDA Consolidation Guide section, and the entries needed in that section to conform to Meaningful Use.  On the right hand side it shows which of those sections appear in the different documents in the consolidation guide.  In looking at this table, it seems impossible to meet the Meaningful Use requirements with the CDA Consolidation guide, but you should realize that you can add sections to any of the documents in the CDA Consolidation Guide that are appropriately specified, so if it were appropriate in a provider workflow to generate a Consultation Note, but it didn't have a section listed as being optional (O) or required (R) for Patient Instructions, you could still include the Instructions Section (perhaps as a subsection under the Care Plan).

It appears from this spreadsheet, that the Consultation Note, CCD 1.1, Discharge Summary and History and Physical Note, Procedure Note and Progress Note could all readily meet the Meaningful Use requirements with just a few added sections.  The operative note doesn't really work without adding quite a few sections that fall outside of the normal workflows for documenting a surgical procedure, but could still be made to work.

I've updated the spreadsheet from yesterday from which these tables came, linking the first sheet to the appropriate rows from these two tables.  Maybe we can convince Robin Raiford to make a pretty poster out of this one too.

Section Data Elements

Section Type

Section Template(s)

CDA Entries

Entry Template(s)

Notes

Consultation Note

Continuity of Care Document

Discharge Summary

History and Physical

Procedure Note

Operative Note

Progress Note

Smoking

Social History

2.16.840.1.113883.10.20.22.2.17

Social History Observation

2.16.840.1.113883.10.20.22.4.38

observation/code = SNOMED CT:229819007 observation/value needs a vocabulary (possibly SNOMED) and value set for: Current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; and unknown if ever smoked

O

O

O

O

O

Vitals

Vital Signs

2.16.840.1.113883.10.20.22.2.4.1

Vital Signs Organizer

2.16.840.1.113883.10.20.22.4.26

O

O

O

R

O

Vital Signs Observation

2.16.840.1.113883.10.20.22.4.27

Problems

Problem

2.16.840.1.113883.10.20.22.2.5

Problem Concern Act

2.16.840.1.113883.10.20.22.4.3

O

R

O

O

O

Problem Observation

2.16.840.1.113883.10.20.22.4.4

History of Past Illness

2.16.840.1.113883.10.20.22.2.20

Problem Observation

2.16.840.1.113883.10.20.22.4.4

Relevant Past problems (not recent history)

O

O

R

O

Medications

Medications

2.16.840.1.113883.10.20.22.2.1.1

Medication Activity

2.16.840.1.113883.10.20.22.4.16

O

R

O

O

O

Admission Medications

2.16.840.1.113883.10.20.22.4.36

Medication Activity

2.16.840.1.113883.10.20.22.4.16

Template does not require Medication Activity, but Rule does

O

Hospital Discharge Medications

2.16.840.1.113883.10.20.22.2.11.1

Medication Activity

2.16.840.1.113883.10.20.22.4.16

R

Medications Administered

2.16.840.1.113883.10.20.22.2.38

Medication Activity

2.16.840.1.113883.10.20.22.4.16

O

Allergies

Allergy

2.16.840.1.113883.10.20.22.2.6.1

Allergy Problem Act

2.16.840.1.113883.10.20.22.4.30

O

R

O

O

O

O

Allergy Observation

2.16.840.1.113883.10.20.22.4.7

Procedures

Procedures

2.16.840.1.113883.10.20.22.2.7.1

Procedure Activity Act

2.16.840.1.113883.10.20.22.4.12

O

O

O

O

O

Procedure Activity Observation

2.16.840.1.113883.10.20.22.4.13

Procedure Activity Procedure

2.16.840.1.113883.10.20.22.4.14

Labs

Lab Results

2.16.840.1.113883.10.20.22.2.3.1

Results Organizer

2.16.840.1.113883.10.20.22.4.1

O

R

R

O

Results Observation

2.16.840.1.113883.10.20.22.4.2

Patient Instructions

Instructions

2.16.840.1.113883.10.20.22.2.45

Instructions

2.16.840.1.113883.10.20.22.4.20

May be included in Care Plan section

Reason for Visit/Admission

Reason for Visit

2.16.840.1.113883.10.20.22.2.12

Problem Observation

2.16.840.1.113883.10.20.22.4.4

O

O

O

O

Chief Complaint and Reason for Visit

2.16.840.1.113883.10.20.22.2.13

Problem Observation

2.16.840.1.113883.10.20.22.4.4

O

O

O

O

Chief Complaint

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Problem Observation

2.16.840.1.113883.10.20.22.4.4

O

O

O

O

O

Reason for Referral

1.3.6.1.4.1.19376.1.5.3.1.3.1

Problem Observation

2.16.840.1.113883.10.20.22.4.4

O

Admission Diagnosis

2.16.840.1.113883.10.20.22.2.43

Problem Observation

2.16.840.1.113883.10.20.22.4.4

Preoperative Diagnosis

2.16.840.1.113883.10.20.22.2.34

Preoperative Diagnosis

2.16.840.1.113883.10.20.22.4.65

R

Care Plan

Care Plan

2.16.840.1.113883.10.20.22.2.10

O

O

R

O

O

O

O

Assessment and Plan

2.16.840.1.113883.10.20.22.2.9

Plan of Care Activity Act

2.16.840.1.113883.10.20.22.4.39

O

O

O

O

Plan of Care Activity Encounter

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance Administration

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

2.16.840.1.113883.10.20.22.4.43

Diagnosis

Assessment

2.16.840.1.113883.10.20.22.2.8

Problem Observation

2.16.840.1.113883.10.20.22.4.4

@codeSystem = 2.16.840.1.113883.6.90 (ICD-10-CM)

Assessment and Plan

2.16.840.1.113883.10.20.22.2.9

Problem Observation

2.16.840.1.113883.10.20.22.4.4

Hospital Discharge Diagnosis

2.16.840.1.113883.10.20.22.4.33

Problem Observation

2.16.840.1.113883.10.20.22.4.4

Postoperative Diagnosis

2.16.840.1.113883.10.20.22.2.35

Problem Observation

2.16.840.1.113883.10.20.22.4.4

R

Postprocedure Diagnosis

2.16.840.1.113883.10.20.22.2.36

Postprocedure Diagnosis

2.16.840.1.113883.10.20.22.4.51

R

Immunizations Administered

Immunization

2.16.840.1.113883.10.20.22.2.2.1

Immunization Activity

2.16.840.1.113883.10.20.22.4.52

O

O

O

O

Patient Decision Aids

Instructions

2.16.840.1.113883.10.20.22.2.45

Instructions

2.16.840.1.113883.10.20.22.4.20

Details about Patient Decision Aids should appear in the Instructions section.

Futured Scheduled Tests

Care Plan

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Observation

2.16.840.1.113883.10.20.22.4.44

Details about future tests should appear in the care plan section

Futured Scheduled Visits

Care Plan

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Encounter

2.16.840.1.113883.10.20.22.4.40

Details about future visits should appear in the care plan section

Referrals

Care Plan

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Encounter

2.16.840.1.113883.10.20.22.4.40

Details about referrals should appear in the care plan section

Join HL7 for a Webinar on mHealth

If you cannot figure what this is about, just consider that up until now, HL7 hasn't had a Mobile Health work group.  I strongly suspect that is about to change.  This call is limited to HL7 members only, so if you aren't a member, it might just be time to join ...

Keith

---

HL7 Mobile Health Join us for a Webinar on March 19, 2pm EDT Space is limited. Reserve your Webinar seat now at: https://www2.gotomeeting.com/register/775041466 HL7 members who are interested in mobile health are invited to an organization-wide Webinar call on Monday, March 19, at 2:00 pm ET.  The call will be chaired by Chuck Jaffe, John Quinn and Austin Kreisler. Those HL7 members interested and able to attend the call must register using the "Register Now" link above.  You must register for the call to receive the dial in and passcode.  Please refer to the Notes section below for important tips on successfully connecting to this HL7 Webinar. Those HL7 members who are interested in mobile health but unable to attend the March 19 Webinar are invited to register their interest using the link below: http://www.surveymonkey.com/s/78Y637K Any outcomes from the March 19 Webinar will be distributed to those who register for the Webinar or register their interest through the survey. NOTES: When connecting to GoToWebinar, please remember the following: • Do not use Skype to access the Webinar audio • 15 minutes prior to the Webinar, it’s recommended that you connect to the Webinar so as to provide ample time for Citrix software to download.  The software download should only take a minute or two.  If it takes longer, cancel the session and reconnect • Remember to enter your Audio PIN, otherwise you will be in 'listen only' mode • If you do NOT log into the Webinar, you will be in 'listen only' audio mode (GoToWebinar does not allow a 'talking mode' unless you enter an Audio PIN, which is only shown after joining the Webinar) • If you have issues connecting to the Webinar or with audio during the Webinar, contact GoToWebinar Customer Support at 1-866-962-6492 Title: HL7 Mobile Health Date: Monday, March 19, 2012 Time: 2:00 PM - 3:00 PM EDT After registering you will receive a confirmation email containing information about joining the Webinar. System Requirements PC-based attendees Required: Windows® 7, Vista, XP or 2003 Server Macintosh®-based attendees Required: Mac OS® X 10.5 or newer

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Defining a Summary Care Record for MeaningfulUse Stage2

In Yesterday's post, I talked about how confusing the descriptions of Summary Care Record were in the Meaningful Use Stage 2 rules.  Today I'm going to work at simplifying those for you.  There are two tables below.  The first table just shows the summarized the results.  The second table provides the detail for the first.

The Name, Gender, Race, Ethnicity, Preferred Language, and Date of Birth are common to all summaries and appear in the <patient> element of the CDA Document in any CDA header.

Provider information also appears in the header and is common across all summaries.

Smoking Status, Vital Signs, Medications, Allergies, Problems, Procedures, Lab Tests and Results, and Care Plan are also common across all summaries, and can be found in appropriate sections of the CDA Document in the consolidated guide.  In some cases, you might want to add sections (e.g., Lab Tests and Results) to a document that doesn't contain it in order to meet the MU Criteria.

Patient Instructions could arguably show up in the Care Plan section, or elsewhere as written text in the summary, but in CDA Consolidation, there is an Instructions section that can be used, and probably should be used in whatever summary is produced, possibly as a subsection under the Care Plan.

The date and location of the visit or stay would show up in any summary in the <encompassingEncounter> element.  Those are not required under the incentives rule, but are under the standards rule for all summaries.  It should be added in incentives.

The reason for visit can show up in several different ways: admission diagnosis, chief complaint, or reason for visit, and there are appropriate sections for those.  It too appears to be missing from the incentives rule.

Section 170.314(e)(2) stands out as the biggest odd-ball in the lot.  It includes medications and immunizations administered, patient decision aids, scheduled tests and visits and referrals.  The medications and immunizations administered should probably be recorded in the respective sections.  Patient Decision aids should be included in patient instructions.  The last three (future plans) should be included in the care plan.   That would normalize it nicely into the other groups.

Growth charts also stand out.  These are not summaries, rather, they are assessments over time that can be crafted from data in multiple summaries.

Care Team members don't show up in Clinical Summaries provided to patients.  Why wouldn't they be present when available?

It isn't clear why diagnoses wouldn't be incorporated when available, or be viewable by the patient.

It isn't clear why immunizations are reported in an ambulatory setting, but not in the inpatient setting (it's fairly common for some kinds of immunizations to be given during inpatient stays).

Rationalizing these data elements across the summaries could easily get us to one or two definitions for summaries.

A spreadsheet containing this content is available.

	Name	Gender	Race	Ethn.	Lang.	DOB	Smoking	Vitals	Meds	Allergy	Probs	Proc.	Labs	Prvdr	Date/Loc	Inst.	Reason	Plan	Team	Diag.		Med/Imm.	Aids	Sch. Test	Sch. Visit	Refrls.	Gth Chrt
170.314(b)(1) Transitions of care -- incorporate summary care record. Upon receipt of a summary care record formatted according to the standard adopted at § 170.205(a)(3), electronically incorporate, at a minimum, the following data elements:	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
170.314(b)(2) Transitions of care--create and transmit summary care record. (i) Enable a user to electronically create a summary care record formatted according to the standard adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
170.314 (e)(1) View, download, and transmit to 3rd party. (i) Enable a user to provide patients (and their authorized representatives) with online access to do all of the following: (A) View. Electronically view in accordance with the standard adopted at § 170.204(a), at a minimum, the following data elements:	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
170.314(e)(1)(B)(2) A summary care record formatted according to the standards adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
170.314(e)(2) Ambulatory setting only -- clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, the following data elements:	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X		X		X	X	X	X	X
All summary of care documents used to meet (this) objective must include the following: ... In circumstances where there is no information available to populate one or more of the fields listed previously, either because the EP, eligible hospital or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital or CAH may leave the field(s) blank and still meet the objective and its associated measure. In addition, all summary of care documents used to meet (this) objective must include the following:	X	X	X	X	X	X	X	X	X	X	X	X	X	X		X		X	X								X

Table 2: Detail

	Name	Gender	Race	Ethn.	Lang.	DOB	Smoking	Vitals	Meds	Allergy	Probs	Proc.	Labs	Prvdr	Date/Loc	Inst.	Reason	Plan	Team	Diag.		Med/Imm.	Aids	Sch. Test	Sch. Visit	Refrls.	Gth Chrt
170.314(b)(1) Transitions of care -- incorporate summary care record. Upon receipt of a summary care record formatted according to the standard adopted at § 170.205(a)(3), electronically incorporate, at a minimum, the following data elements:	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
Patient name	X
gender		X
race			X
ethnicity				X
preferred language					X
date of birth						X
smoking status							X
vital signs								X
medications									X
medication allergies										X
problems											X
procedures												X
laboratory tests and values/results													X
the referring or transitioning provider's name and contact information														X
hospital admission and discharge dates and locations															X
discharge instructions																X
reason(s) for hospitalization																	X
care plan, including goals and instructions																		X
names of providers of care during hospitalizations																			X
and names and contact information of any additional known care team members beyond the referring or transitioning provider and the receiving provider.
170.314(b)(2) Transitions of care--create and transmit summary care record. (i) Enable a user to electronically create a summary care record formatted according to the standard adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
(A) Patient name	X
gender		X
date of birth						X
medication allergies										X
vital signs								X
laboratory tests and values/results													X
the referring or transitioning provider's name and contact information														X
names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving provider																			X
care plan, including goals and instructions																		X
(B) Race and ethnicity. The standard specified in § 170.207(f)			X	X
(C) Preferred language. The standard specified in § 170.207(j)					X
(D) Smoking status. The standard specified in § 170.207(1)							X
(E) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)											X
(F) Encounter diagnoses. The standard specified in § 170.207(m)																				X
(G) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)												X
(H) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)													X
(I) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed													X
(J) Medications. At a minimum, the version of the standard specified in § 170.207(h); and									X
(K) Inpatient setting only. Hospital admission and discharge dates and location															X
names of providers of care during hospitalizations														X
discharge instructions																X
and reason(s) for hospitalization.																	X
170.314 (e)(1) View, download, and transmit to 3rd party. (i) Enable a user to provide patients (and their authorized representatives) with online access to do all of the following: (A) View. Electronically view in accordance with the standard adopted at § 170.204(a), at a minimum, the following data elements:	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
(1) Patient name	X
gender		X
date of birth						X
race			X
ethnicity				X
preferred language					X
smoking status							X
problem list											X
medication list									X
medication allergy list										X
procedures												X
vital signs								X
laboratory tests and values/results													X
provider's name and contact information														X
names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving provider																			X
and care plan, including goals and instructions.																		X
(2) Inpatient setting only. Admission and discharge dates and locations															X
reason(s) for hospitalization																	X
names of providers of care during hospitalization														X
laboratory tests and values/results (available at time of discharge)													X
and discharge instructions for patient.																X
170.314(e)(1)(B)(2) A summary care record formatted according to the standards adopted at § 170.205(a)(3) and that includes, at a minimum, the following data elements expressed, where applicable, according to the specified standard(s):	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
(i) Patient name	X
gender		X
date of birth						X
medication allergies										X
vital signs								X
the provider's name and contact information														X
names and contact information of any additional care team members beyond the referring or transitioning provider and the receiving provider																			X
care plan, including goals and instructions																		X
(ii) Race and ethnicity. The standard specified in § 170.207(f)			X	X
(iii) Preferred language. The standard specified in § 170.207(j)					X
(iv) Smoking status. The standard specified in § 170.207(l)							X
(v) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)											X
(vi) Encounter diagnoses. The standard specified in § 170.207(m)																				X
(vii) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)												X
(viii) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)													X
(ix) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed													X
(x) Medications. At a minimum, the version of the standard specified in § 170.207(h); and									X
(xi) Inpatient setting only. The data elements specified in paragraph (e)(1)(i)(A)(2) of (this) section.
(2) Inpatient setting only. Admission and discharge dates and locations															X
reason(s) for hospitalization																	X
names of providers of care during hospitalization														X
laboratory tests and values/results (available at time of discharge)													X
and discharge instructions for patient.																X
170.314(e)(2) Ambulatory setting only—clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, the following data elements:	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X		X		X	X	X	X	X
Provider's name and office contact information														X
date and location of visit															X
reason for visit																	X
patient's name	X
gender		X
race			X
ethnicity				X
date of birth						X
preferred language					X
smoking status							X
vital signs and any updates								X
problem list and any updates											X
medication list and any updates									X
medication allergy list and any updates										X
immunizations and/or medications administered during the visit																						X
procedures performed during the visit												X
laboratory tests and values/results, including any tests and value/results pending													X
clinical instructions																X
care plan, including goals and instructions																		X
recommended patient decision aids (if applicable to the visit)																							X
future scheduled tests																								X
future appointments																									X
and referrals to other providers. If the clinical summary is provided electronically, it must be:																										X
(i) Provided in human readable format; and
(ii) Provided in a summary care record formatted according to the standard adopted at § 170.205(a)(3) with the following data elements expressed, where applicable, according to the specified standard(s):
(A) Race and ethnicity. The standard specified in § 170.207(f)			X	X
(B) Preferred language. The standard specified in § 170.207(j)					X
(C) Smoking status. The standard specified in § 170.207(l)							X
(D) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3)											X
(E) Encounter diagnoses. The standard specified in § 170.207(m)																				X
(F) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3)												X
(G) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g)													X
(H) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed; and													X
(I) Medications. At a minimum, the version of the standard specified in § 170.207(h).									X
All summary of care documents used to meet (this) objective must include the following: ... In circumstances where there is no information available to populate one or more of the fields listed previously, either because the EP, eligible hospital or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital or CAH may leave the field(s) blank and still meet the objective and its associated measure. In addition, all summary of care documents used to meet (this) objective must include the following:	X	X	X	X	X	X	X	X	X	X	X	X	X	X		X		X	X								X
Patient name.	X
Referring or transitioning provider's name and office contact information (EP only).														X
Procedures.												X
Relevant past diagnoses.											X
Laboratory test results.													X
Vital signs (height, weight, blood pressure, BMI, growth charts).							X																				X
Smoking status.
Demographic information (
preferred language					X
gender		X
race			X
ethnicity				X
date of birth)						X
Care plan field, including goals and instructions, and																		X
Any additional known care team members beyond the referring or transitioning provider and the receiving provider.																			X
In addition, eligible hospitals and CAHs would be required to include discharge instructions.																X
An up-to-date problem list of current and active diagnoses.											X
An active medication list, and									X
An active medication allergy list.										X